RADIOTHERAPY

I. INTRODUCTION

A. THE DISCOVERY OF ROENTGEN RAYS AND RADIOACTIVITY

B. THERAPEUTIC USES OF X-RAYS AND RADIOACTIVITY
C. HISTORICAL DEVELOPMENT IN RADIATION ONCOLOGY (RADIATION THERAPY)
D. MEASUREMENT OF QUALITY AND QUANTITY OF RADIATION BEAMS
E. RADIOBIOLOGY
F. RADIATION PROTECTION
G. TECHNICAL DEVELOPMENT
H. IMPORTANT MILESTONE IN THE HISTORY OF RADIATION THERAPY

II. DEFINITION OF TERMS

III. NEOPLASIA

A. TWO TYPES OF NEOPLASIA

B. CATEGORIZED ACCORDING TO TISSUE OF ORIGIN
C. THREE PATH WAYS OF MALIGNANT NEOLASM
D. THREE MAJOR SUBTYPES OF CANCER
E. CANCER CLASSIFICATION
F. FACTORS THAT INFLUENCE CANCER DEVELOPMENT
G. PREVENTION
H. EARLY DETECTION OF CANCER
I. AMERICAN WARNING SIGNS OF CANCER
J. TUMOR STAGING (TNM)
K. GRADING AND STAGING
L. DIAGNOSTIC AND LABORATORY PROCEDURES
M. RADIOGRAPHIC STUDIES
N. TREATMENT
O. PAIN CONTROL
P. EFFECTIVE TREATMETNOF A MALIGNANT TUMOR WITH IONIZING RADIATION
DEPENDS ON
Q. THERAPEUTIC RATIO

IV. RADIATION THERAPY

A. PRINCIPLES OF CANCER MANAGEMENT

B. RADIOSENSITIVITY OF DIFFREENT TUMORS
C. METHOD OF RADIOTHERAPY
D. RADIATION SOURCES SIMULATORS
E. BRACHYTHERAPY
F. AIMS OF RADIOTHERAPY
G. ROLE OF RADIOTHERAPY TECHNOLOGIST
H. HOW IS RADIOTHERAPY ADMINISTERED
I. FRACTIONATION AND TOLERANCE DOSE

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 J. OXYGEN EFFECT
K. THERAPEUTIC RATIO
L. THERAPEUTIC RATIO
M. TECHNICAL FACTORS IN RADIOTHERAPY
N. DOSE FRACTIONATION AND OVERALL TREATMENT TIME
O. OSE IN RADICAL AND PALLIATIVE RADIOTHERAPY
P. FRACTIONATION
Q. THE 5 R’s OF FRACTIONATED RADIOTHERAPY

V. RADIATION PROTECTION AND SAFETY STANDARDS FOR THE

PRACTICE OF RADIATION THERAPY UTILIZING MEDICAL LINEAR
ACCELARTOR MACHONES IN THE PHILIPPINES

V. CLINICAL ENTITIES

A. CARCINOMA OF THE LARYNX

B. CARCINOMA OF THE SKIN
C. MEDULLOBLASTOMA
D. RETINOBLASTOMA
E. CANCERS TREATED PRIMARILY BY RADIATION THERAPY
F. CANCERS TREATED WITH RADIATION AND SURGERY AND/OR CHEMOTHERAPY
G. THE FUTURE

VI. TREATMENT PLANNING

A. HEAD AND NECK

B. CENRAL NERVOUS SYSTEM AND PITUITARY GLAND
C. THORAX AND BREAST
D. ABDOMEN
E. PELVIS

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I. INTRODUCTION
 Radiation Oncology, radiation therapy or radiotherapy, involves the
treatment of a cancerous tumor or lesion by the precise application
of ionizing radiation.
 The radiation usually administered by a Radiation Therapy
Technologist under the direct supervision of a Radiation Oncologist,
a physician skilled in the art of applying radiation in the treatment of
malignant disease
 Different specialized are routinely consulted in virtually all cases
involving selection of a best plan of treatment for the patient.
 The individual often consulted are specialists in tumor growth,
spread and response to treatment. Other specialist is usually the
surgical and medical oncologist. As the name implies, the surgical
oncologist is the surgeon who deals primarily with cancer patients.
The medical oncologist is usually a certified physician in internal
medicine who has gain additional expertise in the application of
chemical agents in the treatment of cancer
 This coordinated “team approach” to the diagnosis, care and
treatment for cancer patient is essential to ensure the best possible
therapeutic results.
 Although radiation oncology may be used as the only method of
treatment for malignant disease, a more approach is to use
radiation oncology in conjunction with surgery, chemotherapy, or a
combination of the two.
 Some patient may be treated by only surgery or chemotherapy;
however, approximately 70% of all diagnosed cancer are treated
with radiation. The choice of treatment involves consideration in the
number of patient variables such as the patient’s overall physical
and emotional condition, the histologic type of disease, and the
extent and the anatomic position of the tumor.
 If the tumor is small and its margin are well defined, a surgical
alone may be prescribed. On the other hand, if the disease is
systemic, a chemotherapeutic approach may be chosen.
 Most tumors, however, exhibit degrees of size, invasion and spread
and require variation in the treatment approach that in all like hood
will include radiation oncology as an adjunct to or in conjunction
with surgery and chemotherapy. These limitation determine the
goal of treatment – definitive , palliation or an adjunct to surgery
 Once the patient has been fully evaluated and the radiation
oncology chosen as the form of treatment, the optimum therapeutic
approach must be determined.
 Options include teletherapy versus brachytheraphy, single field
versus multifield approach, temporary of permanent implant,
particulate versus non particulate irradiation, and fractionated
versus protracted dose application. Whatever treatment approach
or regimen is decided, a number of variables must be considered,
and the opportunities for error are many.
 The radiation therapy technologist participate in this decision
making process and is responsible for administering and keeping
accurate records of the dose and monitoring the patient’s physical
and emotional well being once the patient begun the treatment
schedule.
 The therapy technologist should have the an understanding of
oncology, radiation physics, anatomy, mathematics and method of
patient care

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 A complete and effective treatment plan is dependent on precise
patient evaluation and diagnosis, excellent patient care, and
meticulous attention to the patient set up throughout the course of
treatment

THE DISCOVERY OF ROENTGEN RAYS AND RADIOACTIVITY

 On Friday, November 08, 1895, while passing an electric current

through a Hittorf-Crooks high vacuum tube, Wilhelm Conrad
Roentgen notice a light coming from a workbench about a yard
away. He identified the shinning object as a piece of paper painted
with barium platinocyanide.
 Realizing that this light must have been caused by a new kind of
rays, he called them x-rays which later became known as roentgen
rays. He continued the investigation of these rays and found that
when he replaced the fluorescence screen with a photographic
plate, he could obtain pictures.
 The most dramatic picture was taken on December 22, only 6
weeks following the discovery of the invisible rays, showed the
bones of his wife’s hand
 On December 28, 1895, only a few weeks after Roentgen’s
discovery, Henri Becquerel began investigating the possibility of
similar rays being produced by a known fluorescent or
phosphorescent substance. He observed the darkening of
photographic plates by uranium salts and realized that these rays
were emitted spontaneously and continuously from the uranium,
thus, radioactivity was discovered
 Marie Curie, who at this time was studying minerals in Paris,
became interested in the phenomenon of radioactivity and chooses
this subject for her doctoral thesis. Pierre Curie eventually joint his
wife in her research, and on July 1898 they discovered Polonium; in
December of the same year, they reported the discovery of Radium
 Both Becquerel and Pierre Curie experienced erythema on the skin
of the chest from carrying small samples of radium in their vest
pockets
 Pierre Curie applied radium to his arm and described in detail the
various phases of a moist epidermitis and his recovery from it. He
also provided radium to physicians, who tested it on patients
 The news of these discoveries spread quickly, and having learned
the redness of the skin was observed by the users of these rays.
 Several physicians began investigating their effect on malignant
tumors; thus, the use of ionizing radiation in the treatment of cancer
began

THERAPEUTIC USES OF X-RAYS AND RADIOACTIVITY

 The discovery of x-rays and radioactivity was promptly followed by

their therapeutic application
 The first therapeutic application of x-rays is reported to have taken
place in January 29, 1896, when a patient with carcinoma of the
breast was treated; by 1899, the first cancer, a basal cell
epithelioma, had been cured by radiation
 The initial dramatic response observed in the treatment of the skin

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 and other superficial tumors generated the hope that a cure for
cancer had finally been found. This hope was soon followed by
disillusionment and pessimism when tumors recurrences and
injuries to normal tissues began to appear.
 The treatment often involved single massive exposures aim at the
eradication of tumors and patient who survived the immediate post
eradication period often developed major complication
 Because of this disappointing result, the use of x-ray to treat tumor
would soon had it not been for laboratory and clinical work of
Claude Regaud and Henri Coutard. They found out that by
administering fractionated doses of radiation (that is, smaller daily
doses rather than a large single dose), they could achieve the same
tumor response but without serious injury to the adjacent normal
tissues
 From the early experience, it was evident that the unique
advantage of radium lay in intracavitary and interstitial applications.
Here, where the radioactivity was placed directly on or inside the
tumor, the radiation first did not have to traverse normal tissue; the
short distance and rapid fall-off of dose offered an advantage in this
setting
 Initially, containers were rather bulky and could be use only for
intracavitary gynecologic implants. In 1914, methods were
developed for collecting radon (a daughter product of radium) is
small glass tubes, which were then placed inside hollow metal
seeds. Like radium needles, these could be inserted directly into
the tumors. Radium needles and radon seeds were very popular for
many years but have been more recently been replaced by safer,
artificially produced isotopes
 The clinical pioneers in radiation therapy, mostly surgeons and
dermatologist, used the ‘erythema dose’, or radiation dose
necessary to cause redness of the skin, to estimate the proper
length of the treatments
 It was recognized early that accurate dosimetry was fundamental to
success in any type of radiation treatment
 In radium therapy, this comprised three parts; the accurate
measurement of the various source, the determination of the
radiation output of each source in terms of acceptable units, and a
knowledge of distribution of radiation within the tissues under
treatment
 Until 1911, there was no satisfactory methods to standardize
radium
 Madame Curie then began to prepare an accurate standard of
carefully weighed quantities of pure radium salts (8.25 roentgen per
hour at 1cm from the source)

HISTORICAL DEVELOPMENT IN RADIATION

ONCOLOGY (RADIATION THERAP

 Historically, ionizing radiation was applied to obtain a radiographic

image of an individual’s internal anatomy for diagnostic purposes.
 The resulting image depended on many variables, including the
energy the beam, processing technique and materials in which the
image was recorded and most importantly the amount of energy
absorbed by the various organ of the body. This transfer of energy

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 from the beam of radiation to the biologic system and the
observation of the effects of this interaction became the foundation
of radiation oncology
 Two of the most obvious and sometimes immediate biologic effect
observes during the early diagnostic procedures were loss of hair
(epilation) and the reddening of the patients skin (erythema)
Epilation and erythema resulted primarily from the great amount of
energy absorbed by the skin of the patient during radiographic
procedures. This short term induced radiation induced effects
afforded radiographic practitioners an opportunity to expand the use
of radiation to treat condition ranging from relatively benign
maladies such as hypertrichosis (excessive hair), acne and boils to
grotesque and malignant disease such as lupus vulgaris and skin
cancer
 The initial dramatic response observed in the treatment of the skin
and other superficial tumors generated the hope that a cure for
cancer had finally been found. This hope was soon followed by
disillusionment and pessimism when tumors recurrences and
injuries to normal tissues began to appear. The treatment often
involved single massive exposures aim at the eradication of tumors
and patient who survived the immediate post eradication period
often developed major complication
 The first reported application of ionizing radiation to a patient for the
treatment of a more in depth lesion was begun in January 29, 1896
by Dr. Emile H. Grubbe. Dr. Grubbe is reported to have irradiated
for therapeutic purposes a woman with carcinoma of the left breast.
This event occurred only 3 months after the discovery of x-ray by
WC Roentgen. Although Dr. Grubbe neither expected nor observed
any dramatic results from irradiation of the patient, the event is
significantly simply because it occurred
 The first reported case of patient being treated with ionizing
radiation and considered to have been cured was performed by Dr.
Clarence E. Skinner of New Haven, Connecticut, in January 1902.
Dr. Skinner treated a woman who had a diagnosed malignant
fibrosarcoma. During the next two years and three months the
woman received a total of 136 application of x-ray. In April 1909, 7
years after the initial application of the radiation , the woman was
free of disease and considered to be “cured’.
 As more and more data was collected, the interest of radiation
therapy grew. More sophisticate equipment, a greater
understanding of the effect of ionizing radiation, an appreciation of
the time dose relationship and a number of other related
breakthroughs gave impetus to the interest in radiation therapy and
led to its evolution in medical specialty.

MEASUREMENT OF QUALITY AND QUANTITY OF

RADIATION BEAMS

 During the early years of radiology, the methods measuring quality

(or penetrating power) and quantity of x-ray beam were
unsatisfactory. Direct measurements of radiation quality were made
by means of a “penetrometer” which was introduced by Benoist in
1901
 Also at the beginning of the century, Holzknecht described a

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 “chromoradiometer” an instrument to measure quantity of dose. It is
consisted of small disks of a fused mixture of potassium chloride
and sodium carbonate
 Another device, a “radiometer” was developed in 1904 to measure
quantity of dose. This device was use for many years, primarily by
dermatologist
 in 1928, H. Geiger and W. Mueller constructed an improved
detector tube based on a counter built as early as 1906. In various
modified forms, both of these instruments were used well into the
1960’s
 Antoine Beclere in Paris, Gosta Forssell in Stockholm, J.J.
Thompson in Liverpool, and George Pfahler in Boston were among
the pioneers who laid the groundwork of radiation therapy
 In 1913, the term half value layer or HVL (now Half Value Thickness
or HVT) was suggested as a measure of quality
 It was not until 1928 that the roentgen was accepted as a unit of
measurement for x-ray and gamma rays was internationally
accepted and in 1953, the International Commission on
Radiological Units (ICRU) recommended the rad as the unit of
absorbed dose. The rad has more recently replaced by the
centigray (cGy)

RADIOBIOLOGY

 During the first three decades of this 20 th century, Radiobiologist

and Radiotherapist worked closely together in an effort to
understand the intricate phenomena of the biological effect caused
by ionizing radiation
 During the 1920s and 1930s, protracted fractionated methods were
formulated and the relative radiosensitivity of different tissues were
studied primarily by Claude Regaud and Henri Coutard in France
 With the beginning of the fractionated radiation therapy, many new
biological question were raised and as improved cancer cure rates
were experienced; radiobiologist explored the significance of repair,
recovery, reoxygenation, redistribution and repopulation

RADIATION PROTECTION

 The Biologic Effectiveness of ionizing radiation in living tissue is

dependent partially on the amount of energy that is deposited within
the tissue and partially on the condition of biologic system. The term
used to described this relationship are “linear energy transfer” (LET)
and “relative biologic effectiveness” (RBE)
 Let values are express in thousands of electron volts deposit per
micron of tissue (kEv/um) and will vary, of course, depending on the
type of radiation being considered. Particles, because of their mass
and possible charge, tend to ineratc readily with the material
through which they are passing and therefore have a greater LET
value
 The effectiveness of ionizing radiation on a biologic system depend
not only on the amount of radiation deposited but the also on the
state of biologic system. One of the first law of radiation biology,
postulated by Bergonie and Tribondeau, stated in essence that the

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 radiosensitivity of the tissue is dependent on the number of
undifferentiated cells in the tissue, the degree of mitotic activity of
the tissue and the length of time that cells of the tissue remain in
active proliferation. Although exception exists, the preceding is true
in most tissues. The primary target of ionizing radiation is the DNA
molecule, and the human cells are most radiosensitive during
mitosis. Thus, each group of cell or tissues may respond directly ,
relative to its radiosensitivity, depending on the aforementioned
factors
 The need for protective measures was eventually acknowledge,
and the use of x-rays was thereafter limited to physicians’ offices.
During the ensuing years, much effort was put into improving the
equipment and techniques to reduce the radiation exposure
 The recognition, as early as 1900, of increased distance, short
exposure time and the use of shielding as measure to help reduce
the incidence of radiation injuries led to the development of
shielded storage safes and long handled tools for handling radium
 Early on, the practice of what was later known as radiobiology was
carried by electrician and photographer as well as by physicians
 During the 1920s, methods of measuring dose were developed and
quantitative measurements of radiation exposure were introduced.
The used of film badges was recommended during the 1920s;
during the 1930s, portable survey meters and ionization chambers
became standard equipment in most hospitals
 The concept of ALARA is based on the idea that the radiation
exposure should always be minimal and all reasonable precautions
should be exercise even when the exposure is well below the
permissible levels

TECHNICAL DEVELOPMENT

Period 1920-1940
 The equipment used in the treatment of malignant disease
during the first year of radiation therapy was temperamental
and primitive; it also has very low penetrating power
 During 1920’s Coolidge invented a vacuum x-ray tube capable
of operating peak kilo voltage (kVp) of 200-250. With such
machine, more deep seated tumor could be treated
 Improved treatment techniques were multiple beams aimed at
the tumor from different direction, the so called cross fire
technique was also used.
 The erythema dose was replaced during this era by first
physical unit Roentgen
 The discovery of artificial radioactivity in 1934 had profound
impact on the future of brachytherapy; however the use of
radium continued for many years
 It was not until WWII that neutron reactors, which are capable
of producing artificial radionuclide in large quantities, were
developed; isotopes for medical use were thereafter produced
on a large scale
 The combined treatment of external beam with intracavitary
radium was used during this time period and elaborate system
for calculating the combined dose were devised

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 Period 1940-1960
 The first used of super voltage radiation therapy equipment
then considered to be anything operating at greater than one
million volts occurred in 1937 at Saint Bartholomew’s Hospital
in London.
 Simulator machine became available
 Concentrate radiation dose in the tumor while minimizing the
dose to the adjacent normal tissue followed
 Treatment-planning computers began to appear

Period 1960 up to Present

 Modern development in electronics and computers
 Some modern treatment machine equipped with multileaf
collimators
 Powerful treatment-planning computers capable of three
dimensional dose calculations represent a major contribution to
radiotherapy
 Cobalt 60 and Cesium 137 replaced radium in intracavitary
gynecologic applications (most popular isotopes Iridium 192)
 The development of after loading technique was major step in
reducing the exposure to a large number of staff
 More recently, remote after loading equipment for
brachytherapy has been developed

Significant improvement made in the deign and versatility of

a) Treatment machine
b) Simulators
c) Treatment-Planning Computers
d) Instrument to measure the map dose
e) Computed Tomography
f) Magnetic Resonance Imaging

IMPORTANT MILESTONE IN THE HISTORY OF

RADIATION THERAPY
1895
 November 08: Wilhelm Conrad Roentgen discovered the invisible
rays,which he subsequently called x-rays

1896
 January 29: The first x-ray treatment of cancer patient was
delivered by Dr. Emile Grubbe
 Antoine Henri Becquerel discovered radioactivity
 Claude Regaud and Henri Coutard- fractionated doses of radiation

1897
 Joseph John Thomson announced the finding of negatively charge
particles, which he called electron
 Ernest Rutherford found two types of radiation from uranium, which
he called alpha and beta rays

1898
 December: Marie and Pierre Curie discovered radium
 P.von Villard discovered gamma rays and found them to be similar to x-rays

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1899
 Basal cell epithelioma (SKIN CANCER) first cured by radioactive
substance

1901
 Wilhelm Conrad Roentgen was awarded the first Nobel Prize in
Physics For his discovery of x-rays

1902
 First documented case of cancer “cure” using ionizing radiation by
Dr. Clarence E. Skinner
 Guido Holzkneeht presented his chromoradiometer, a device built
to measure the Quantity of radiation administered

1903
 Antoine was awarded a Nobel Prize in Physics for the discovery of
radioactivity
 Marie and Pierre Curie was awarded a Nobel Prize in Physics for
their Work on radioactivity

1906
 J. Bergonie and Tribondeau postulated the first law of
radiosensitivity
 H. Geiger and Ernest Rutherford developed an instrument to count
Alpha Particle. With the assistance of W. Mueller, this device was
later improved to detect and count other types of radiation.

1908
 P.von Villard proposed a unit dose based on ionization of air by x-
rays

1913
 The half value layer was suggested as a term for the expression of
the quality of roentgen rays

1922
 Arthur Holly Compton discovered the change in the wavelength of
scattered x-rays, the “Compton Effect”

1925
 H. Fricke and Otto Glasser developed the thimble ionization
chamber.

1928
 The Commission on Measures and Units proposed the roentgen
(coulomb/kg) as an international unit dose
 Geiger and Muller developed and improved Geiger counter tube on
the basis of Geiger-Rutherford point counter built in 1906.
 Glasser, Portman and Seitz built the condenser dosimeter for the
measurement of x-rays and radiation from the radioactive
substances. This type of dosimeter has subsequently known as the
Victoreen condenser R-meter

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1932
 E.O. Lawrence invented the cyclotron
 Luriston S. Taylor developed a standard air-ionization chamber to
determined the value of the roentgen

1933
 R.J. Van de Graaf built electrostatic generators capable of
producing up to 12 million volts.

1934
 Frederick Joliot and his wife, Irene Joliot-Curie (Marie and Pierre
Curie’s daughter), produced artificial radioactivity by bombarding
aluminum and alpha particles.

1937
 The Fifth International Congress of Radiology (Chicago) accepted
the roentgen as an international dosage unit for x-ray and gamma
radiation.

1939
 The treatment of cancer patients with the neutron beam from the
cyclotron was begun by E.O Lawrence and R.S. Stone

1940
 Kerst constructed the betatron, with which electrons were
accelerated to energies of 20 million electron volts (MeV) and later
to 300 MeV.

1951
 The first teletheraphy units employing cobalt-60 were used in
radiation Therapy (Saskatoon,Saskatchewan and London, Ontario
Canada)

1952
 The first electron linear accelerator designed for radiotherapy was
installed (Hammersmith Hospital, London)

1953
 The Seventh International Congress Of Radiology (Copenhagen,
Denmark) adopted the rad as the unit of absorbed Dose of any
ionizing radiation.

1960’s
 Treatment-planning computers were developed

1971
 Geoffrey N. Hounsfield invented computed tomography.

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II. DEFINITION OF TERMS
Absorbed Dose
 Amount of ionizing radiation absorbed per unit of mass of irradiated
material as it passes through matter

Accelerator (Particle)
 Device that accelerates changed subatomic particles to great
energies. These particles produce x-ray and neutrons and may be
used to direct medical irradiation and basic physical research.
Medical Units include linear accelerators, Van de Graaf units,
betatron and cyclotron

Air Dose
 Dose of radiation measured in roentgen in free air, uncorrected for
absorption or backscatter

Anaplasia
 Alteration of cell to more embryonic state; may be used to describe
particular type of tumor

Attenuation
 Removal of energy from beam of ionizing radiation when it
traverses matter, by disposition of energy in matter and by
deflection of energy out of the beam

Betatron
 Electron accelerator that uses magnetic induction to accelerate
electron in circular path; also capable of producing photons

Bolus
 Tissue equivalent material (beeswax, petroleum gauze, Silly Putty)
placed around curved, irregularly shaped anatomic areas to obtain
more uniform dosage distribution

Brachytherapy
 Placement of radioactive nuclides in or on the neoplasm to deliver
cancericidal dose

Cancer/New growth
 Term frequently applied to malignant disease: neoplasm (new
growth) or oma (tumor)

Carcinogen
 Any cancer producing substance or material such as nicotine,
radiation or ingested uranium

Chemical Dosimeter
 Detector for indirect measurement of radiation by indicating extent
to which radiation causes definite chemical change to take place
(e.g. TLD)

Cobalt 60
 Radioisotope with half life of 5.25 years, average gamma rays intensity of
1.25 mEv, and the ability to spare skin with buildup depth in tissue of 0.5cm

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Collimator
 Diaphragm or system of diaphragms made of radiation-absorbing
material that define dimension and direction of beam

Compensating Filter
 Filter designed to modify dose distribution within patient. Filters may
be designed to account for patient shape, size or position (e.g
wedge filter)

Contamination
 Radioactivity in inappropriate places such as technologist hands

Cure
 Usually, 5 year period after completion of treatment during which
time patient exhibit no evidence of disease

Decay or Disintegration
 Transformation of the radioactive nucleus, resulting in the emission
of radiation

Differentiation
 Acquisition of cellular functions that differ from functions of original
cell type

Dose Rate
 Radiation dose delivered per unit of time, usually roentgen per
minute

Dosimeter
 Device (e.g. Film badge, ionization chamber, Geiger counter) that
measure radiation exposure

Etiology
 Study of causes of disease

Field
 Geometric area defined by collimator or radiotherapy unit at skin
surface

Filter
 Attenuator inserted in beam near source to modify beam quality in
desired way. Materials used often are copper, aluminum and lead

Fission
 Breaking apart of uranium 235 nucleus, liberating energy and
neutrons, which are used in producing radioactive isotopes in
reactor

Fractionation
 Dividing of total planned dose into number of smaller dose to be
given over long period. Consideration must be given to biologic
effectiveness of smaller doses

Gamma Ray
 Electromagnetic radiation that originates from radioactive nucleus

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 and causes ionization in matter; identical in properties to x-ray

Grenz Ray
 X-ray generated at 20 kVp or less

Half-Life
 Time (specific for each radioactive substance) required for
radioactive material to decay to half of its initial activity. Types are
biologic and effective

Half-Value Layer
 Thickness of attenuating material inserted in beam to reduce beam
intensity to half value

Ionization
 Process in which one or more electrons are added to or removed
from atoms, creating ions. Can be caused by high temperatures,
electrical discharges, or nuclear radiation

Isodose Curve
 Curve or line drawn to connect points of identical amounts of
radiation in given field

Metastasis
 Transmission of cells or groups of cells from primary tumor to sites
elsewhere in the body

Oncologist
 Doctors of medicine specializing in the study of tumors

Oncology
 Study of tumors

Protraction
 Delivery of tumor dose in extended, uninterrupted time period

Radiation Oncologist
 Doctor of medicine specializing in use of ionizing radiation in
treatment of disease

Radiation Oncology
 Medical specialty involving the treatment of cancerous lesion using
ionizing radiation

Radiation Therapy
 Older term used to define medical specialty of treatment with
ionizing radiation

Radiation Therapy Technologist

 Person trained to assist and take directions from radiation therapist
in used of ionizing radiation in treatment of disease

Radioactive
 Pertaining to atoms of elements that undergo spontaneous
transformation, resulting in emission of radiation

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Radiocurable
 Susceptibility of neoplastic cells to cure (destruction) by ionizing
radiation.

Radiosensitivity
 Responsiveness of cells to radiation

Radium (Ra)
 Radionuclide (atomic number 88; atomic weight 226; half-life 1622
years) used clinically for radiation therapy. In conjunction with it is
subsequent transformation, radium emits alpha and beta particles
and gamma rays. In encapsulated form, it is used for various
intracavitary radiation therapy applications such as that for cancer
of the cervix

Reactor
 Cubicles in which isotopes are artificially produced

Roentgen (R)
 Unit of exposure dose, based on the extent of ionization in air and
defined as 2.58 x 10 -4 coulombs/kg of dry air, which is equivalent
to 1 electrostatic unit of charge/cc or 0.001293 gm of dry air; 1.16 to
10¹² ion pairs/gm of air; 2.08 x 10 ion pairs/gm of air; or absorption
of 87 ergs of energy/gm of air

Scattering
 Process in which the trajectory of particle of photon is changed;
caused by collision of atoms, nuclei and other particles

Sequelae
 Reaction or side effect of ionizing radiation on tissue

Skin Sparing
 In supervoltage beam therapy, reduced skin injury per roentgen
exposure when electron equilibrium is not present at advance portal
but occurs below skin. Occurs from 0.5 to 5.0 cm deep depending
on energy

Teletherapy
 Radiation therapy technique for which source of radiation is is at
some distance from the patient

Tumor Volume
 Portion of anatomy that includes tumor and adjacent areas of
invasion

Undifferentiation
 Lack or absence of normal cell differentiation

Unstable
 In excited, active state; with nucleus possessing excess energy

Van de Graaf
 Electrostatic machine in which the electronically charged particles
are sprayed on moving belt and carried by it to build up high

15
 potential on insulated terminal. Charged particles are then
accelerated along discharged path through vacuum tube by
potential difference between insulated terminal and opposite end of
the machine. Often used to inject particles into larger accelerators.

III. NEOPLASIA
 Because tissue cells compromised primarily water, most of the
ionizing radiation occurs with water molecules. These events are
called indirect effect and result in the formation of free radicals. This
highly reactive free radical may recombine, resulting in no biologic
effect whatsoever. Or they may combine with other atom and
molecules to produce biochemical change that may be deleterious
to the cells.
 The possibility also exists that the radiation may interact with an
organic molecule or atom which results in the inactivation of the
cell; this reaction is called direct effect. Because ionizing radiation is
nonspecific (will interact with normal cells as readily with tumor
cells), it is obvious that cellular damage will both occur in normal
and abnormal tissue.
 The deleterious effect however, will be greater in the abnormal cells
because a greater percentage of the abnormal cells are undergoing
mitosis; they are also tends to be more poorly differentiated.
 In addition, normal cells have the capability for repairing sublethal
damage than do tumor cells. Because of these reasons, greater cell
damage will occur to abnormal than to the normal cells for any
given increment of dose.
 The effect of the interactions in either normal or tumor cells may be
expressed in a number of ways:

1. Loss of reproductive ability

2. Metabolic Changes
3. Cell transformation
4. Acceleration of the aging process
5. Cell mutation

 Certainly the greater the number of interaction that occur, the

greater the possibility of cell death. The preceding information leads
to a categorization of tumors according to their radiosensitivity

1. Very Radiosensitive
a. Gonadal germ cell tumor (seminoma of the testis,
dysgerminoma of the ovary
b. Lymphoproliferative tumors (Hodgkin’s Disease,
Lymphoma)
c. Embryonal Tumors (Wills Tumor of the Kidney,
Retinoblastoma)

2. Moderately Radiosensitive
a. Epithelial tumors ( squamous and basal cell carcinoma of
the skin)
b. Glandular tumors (adenoma carcinoma of the prostate)

16
 3. Relatively Radioresistant
a. Mesenchymal tumors (sarcomas of bone, connective tissue
and muscle)
b. Nerve tumors (glioma, melanoma)

 A tumor must have some degree of radiosensitivity to be

considered in radiation treatment; however, radiosensitivity does
not necessarily imply radiocurability.
 T he characteristic that make a tumor more radiosensitive , for
example , fast growth and vascularity , also caused it to be more
extensive lesion (e.g Lymphosarcoma). This situation tend to
compromise the treatment approach
 Conversely some tumors that have been classified as
radioresistant, for instance, carcinoma of the tongue, may be
considered radiocurable

NEOPLASIA
 Cancer or “new growth” has yet to be precisely define; however, a
number of attempts, such as the following has been made

1. Cell in which the normal growth – controlling mechanism is

altered, permitting progressive growth
2. A group of disease of unknown causes that occur in all human
and animal population and arise in all tissue that are composed
of potentially dividing cells
3. A disease of tissue organization
4. A genetic disease of somatic cells resulting from a mutation of a
previously normal cell into a new cell of enduring malignancy
5. So called spontaneous auto aggressive disease of a tissue
initiated by random gene mutation in stem cell

Some Basic facts known about Cancer

1. Cancer can arise from cell that have the ability to proliferate
2. Tumor cells may mature inadequately and may be spoken of as
“anaplastic” or undifferentiated
3. Cancer may arise after a variety of stimuli (chemical, physical
or viral) but usually after a prolonged latent period
4. No distinct ultra structural nor biochemical difference between a
cancer and a normal cells have been positively identified
5. A few cancer regress spontaneously

 Literally means “new growth” and refers to an abnormal proliferation

of cells that are no longer controlled by factors that govern the
growth of normal cells.

TWO TYPES OF NEOPLASIA

1. Benign
- Benign tumors are characterized by entirely localized growth
and are usually separated from the neighboring tissue by
surrounding capsule
- Benign tumors are generally grow slowly and in structure

17
 closely resemble the tissue of origin

2. Malignant
- Malignant tumors has the ability to spread beyond the site of
origin
- Tumors invade the neighboring tissue by direct extension or
infiltration or may disseminate to distance site forming
secondary growth known as metastases

CATEGORIZED ACCORDING TO TISSUE OF ORIGIN

 Although cancers may arise in any human tissue, they are usually
categorized under six general heading

TISSUE OF ORIGIN TYPE OF TUMOR

EPITHELIUM
- Surface Epithelium Carcinoma
- Glandular Epithelium Adenocarcinoma
CONNECTIVE TISSUE
- Bone Osteosarcoma
- Fat Liposarcoma
HEMATOPOIETIC TISSUE
- Plasma Cells Multiple Myeloma
- Erythrocytic Tissue Erythroleukemia
NERVE TISSUE
- Glial tissue Glioma
- Neuroectoderm Neuroblatoma
TUMORS OF MORE THAN ONE
TISSUE Nephroblastoma
- Embryonic kidney
OTHERS
- Testis Seminoma
- Thymus Thymoma

THREE PATH WAYS OF MALIGNANT NEOLASM

1. Seeding (diffuse spread) of cancer occurs when neoplasm invade
a natural body cavity e.g. tumor of the GIT

2. Lymphatic Spread is the major metastatic route of carcinomas

especially those of the lung and breast. The pattern of lymph node
involvement depends on the site of the primary neoplasm and the
natural lymphatic pathways of drainage of that region. Carcinoma of
the breast usually arises in the upper outer quadrant and first
spread to the axillary’s nodes. Medial breast lesions may drain
through the chest wall to the nodes of internal mammary artery

3. Heterogeneous spread of cancer is a complex process involving

several steps. Tumors cells invade and penetrate blood vessels
and are released as neoplastic emboli into the circulation. These
emboli of tumors cells are trapped in small vascular channels of
distant organs, where they invade the walls of arresting vessels and
infiltrates and multiply in the adjacent tissue. The localization of

18
 hematogenous metastases tends to be determined by the vascular
connections and anatomic relation between the primary neoplasm
and the metastatic sites

e.g. carcinoma arising in the abdominal organs such as GIT

tends to metastasize to the liver because the flow of portal vein
blood to that organ

THREE MAJOR SUBTYPES OF CANCER

1. SARCOMAS arises from the connective and supportive tissue,
such as bone, cartilage, nerve, blood vessels, muscle and fat

2. CARCINOMAS, which include the most frequently occurring forms

of human cancer, arise from epithelial tissue, such as the skin and
the lining of the body cavities and organs, and the glandular tissue
of the breast and prostate. Carcinomas with a structure resembling
skin are termed SQUAMOUS cell carcinomas. Those that resemble
glandular tissue are called ADENOCARCINOMA

3. LEUKEMIAS and LYMPHOMAS include the cancers that involve

blood forming tissue and are typified by the enlargement of the
lymph nodes, the invasion of the spleen and bone marrow and the
overproduction of immature white blood cells

CANCER CLASSIFICATION

1. Solid tumors
- Associated from the organ which they developed, such as
breast cancer or lung cancer

2. Hematological cancers
- originate from blood-cell forming tissues, such as leukemia,
lymphomas and multiple myeloma

FACTORS THAT INFLUENCE CANCER DEVELOPMENT

1. Environmental Factors

a. Chemical Carcinogen
- Factors include industrial chemicals, drugs and tobacco
b. Physical Carcinogen
- Factors include ionizing radiation (diagnostic and
therapeutic rays) and ultraviolet radiation (sun, tanning
beds and germicidal lights), chronic irritation and tissue
trauma
c. Viral carcinogen
- Viruses capable of causing cancer are known as oncovirus,
such Epstein-Barr virus, Hepatitis B virus and human
pappilomavirus
d. Helicobacter Pylori
- Infection is associated with an increased risk of gastric

19
 cancer

2. Obesity and dietary factors

3. Genetic predisposition
4. Age
5. Immune function

PREVENTION
 Avoidance of known or potential carcinogens and avoidance or
modification of the factors associated with the development of
cancer cells

EARLY DETECTION OF CANCER

1. Mammography
2. Papanicolaou’s (Pap) test
3. Stool for occult blood
4. Sigmoidoscopy, colonoscopy
5. Breast self examination and clinical breast examination
6. Testicular self examination
7. Skin inspection

Breast Self Examination

- Perform 7-10 days after menses
- For post menopausal clients or clients who had a hysterectomy
should select a specific day of the month and perform BSE
monthly on that day

Testicular Self Examination

- Perform same day each month

AMERICAN WARNING SIGNS OF CANCER

C - Change in bowel/bladder pattern

A - A sore that does NOT heal
U - Unusual Bleeding or discharge
T - Thickening of lump in Breast or elsewhere
I - Indigestion or difficulty swallowing
O - Obvious change in warts or mole
N - Nagging cough or hoarseness of voice
U - Unexplained anemia (A- Anemia)
S - Sudden weight loss (L- Loss of weight)

TUMOR STAGING (TNM)

 To facilitate the exchange of patient information from one physician

to another , a system of classifying tumors based on anatomic and
histologic consideration
 This system was the TNM classification which describes tumor
according to

20
 1. The size of the Primary Lesion
2. The involvement of the regional lymph node
3. Occurrence of metastases

Primary Tumor (T)

Tx 1º tumor cannot assess
To NO 1º tumor
Tis 1º tumor in situ
T1 1º tumor 1cm

Regional Lymph node (N)

Nx Regional lymph node cannot be assess
No NO RLN (has not spread)
N1 Single RLN (has spread)

Distant Metastasis (M)

Mx Distant metastasis cannot be assess
Mo NO distant metastasis
M1 distant metastasis (one organ)

GRADING AND STAGING

 Methods used to described the tumors
 These methods described the extent of the tumor, the extent to
which malignancy has increased in size, the involvement of regional
lymph node and metastatic development. (TNM)

GRADING
 assess its aggressiveness or degree of malignancy
 The grade of the tumor usually indicates its biologic behavior and
may allow prediction of its responsiveness to certain therapeutic
agents
 classifies the cellular aspects of the cancer

STAGING
 Refers to extensiveness of a tumor at its primary site and the
presence or absence of metastases to lymph nodes and distant
organs such as the liver, lungs and skeleton
 The staging of a tumor is often critical to the choice of appropriate
therapy
 classifies the clinical aspect of the cancer and the degree of
metastasis at diagnosis

DIAGNOSTIC AND LABORATORY PROCEDURES

1. BIOPSY
 Remains the only definitive method for the diagnosis of a cancer. It
involves examination of a section of tissue removed from the tumor
itself or from a metastasis.

21
 Types; * Tissue examination
A. needle 1. Frozen section
B. incisional 2. Permanent paraffin section
C. excisional

2. BLOOD ANALYSIS
A. CBC
1. RBC – 4 to 5 million cu.mm
˂ RBC - Anemia
˃ RBC - Erythrocytosis or Polycythemia

2. WBC – 5-10 thousand cu.mm

˃ WBC - Leukopenia
˂ WBC – Inflammatory process/ infection
˃ 100,000– Immature (abnormal proliferation of WBC- Leukemia)

B. Platelets 150T-400T
˃ PLT - Thrombocytopenia
˂ PLT - Thrombocytosis

RADIOGRAPHIC STUDIES

1. X-ray – Use to view unseen or hard to image objects

2. UTZ – use measure the reflection of the inner structure of an organ
3. CT scan - use to generate 3 dimensional image of the inside of an
object
4. MRI - Use visualized the function and structure of the body

TREATMENT
 The traditional means of treating cancer have been surgery,
radiation therapy and chemotherapy
 Currently, studies are under way of the usefulness of
immunotherapy and biologic response modifiers

1. SURGERY
 Is indicated to diagnose, stage and treat cancer
1. Prophylactic surgery
2. Curative surgery
3. Palliative surgery
4. Reconstructive or rehabilitative surgery

2. CHEMOTHERAPY
 Kills or inhibits the reproduction of neoplastic cells and kills normal
cells
 Normal cells that profoundly affected includes those of the skin,
hair, lining of GIT, spermatocytes and hematopoietic cells
 May be combined with other treatment such as surgery or radiation
therapy
 Common side effects includes fatigue, alopecia, nausea and
vomiting, mucositis, skin changes and myelosuppression
(neutropenia, anemia and thrombocytopenia)

22
3. RADIATION THERAPY
 Treatment of disease, primarily malignant tumor, using
electromagnetic and particle radiation
 Destroys cancer cells with minimal exposure to normal cells to the
damaging effect of radiation; the damage cells die or unable to
divide
 Effective on tissue directly within the path of radiation beam
 Side effects include local skin changes and irritation, alopecia,
fatigue (most common) and altered taste sensation; effects vary
according to site of treatment

PAIN CONTROL
Causes of pain:
1. Bone destruction
2. Obstruction of an organ
3. Compression of peripheral nerve
4. Infiltration, distention of tissue
5. Inflammation, necrosis
6. Psychological factors, such as fear or anxiety

EFFECTIVE TREATMETN OF A MALIGNANT TUMOR WITH

IONIZING RADIATION DEPENDS ON
1. The extend of the disease diagnosis
2. The histologic type of tumor
3. The general well being of the patient
4. The location of the tumor
5. Whether the tumor is radiocurable

THERAPEUTIC RATIO
 To treat tumor definitively requires that the tumor be located in a
tissue that is more radioresistant than the tumor itself
 The therapeutic ratio (TR) was designed to assist in the
determination of where a tumor can be treated for cure, taking into
account the normal tissue tolerance dose and the tumor lethal dose
 If the TR is less than 1, the chance of cure is much less likely than if
the TR is greater than 1

TR = Normal tissue tolerance dose

Tumor tissue lethal dose

IV. RADIATION THERAPY

PRINCIPLES OF CANCER MANAGEMENT

1. Surgery Alone – the treatment of choice
a. Lower esophagus, stomach, colon, pancreas. Kidney
b. Thyroid
c. Melanoma
d. Hepatocellular carcinoma

23
 e. Keratoacanthoma

2. Radiotheraphy – the treatment of choice

a. oral cavity, lip, tongue, cheek
b. Nasophraynx
c. Orophraynx
d. Hypophyrnx
e. Nasal cavity
f. Larynx
g. Skin cancer (except melanoma)
h. Cervix
i. Bladder
j. Testis – seminoma
k. Hodgkin’s disease (early)
l. Non-Hodgkin’s lymphoma (early)
m. Medulloblastoma
n. Astrocytoma (grade 3 and 4)
o. Retinoblastoma

3. Cytotoxic (Chemo) Therapy – the treatment of choice

a. Acute and Chronic leukemia
b. Hodgkin’s disease (advance)
c. Non Hodgkin’s lymphoma (advanced)
d. Testicular teratoma
e. Choriocarcinoma
f. Small cell lung cancer
g. Rhabdomyosarcoma
h. Neuroblastoma

Radiosensitivity of Different Tumors

Highly Sensitive
1. Lymphoma
2. Seminoma
3. Myeloma
4. Ewing’s sarcoma
5. Wilm’s tumor

Moderately Sensitive
1. Small cell lung cancer
2. Breast cancer
3. Basal cell carcinoma
4. Medulloblastoma
5. Teratoma
6. Ovarian cancer

Relatively Resistant
1. Squamous cell carcinommaof lung
2. Hypernephroma
3. Rectal carcinoma
4. Bladder carcinoma
5. Soft tissue sarcoma
6. Cervical cancer

24
Highly Resistant
1. Melanoma
2. Osteosarcoma
3. Pancreatic carcinoma

Note:
1. Most radiosensitive tissue of the body – Bone Marrow
2. Least radiosensitive tissue of the body – Nervous tissue/Brain
3. Most radiosensitive blood cell – Lymphocyte
4. Least radiosensitive blood cell – Platelet
5. Most common organ to be affected by radiation – Skin
(erythema earliest sign)
6. Most radioresistant organ – Vagina
7. Most common mucosa to be affected by radiation – Intestinal
mucosa

METHOD OF RADIOTHERAPY
1. Teletherapy
2. Brachyteraphy

TELETHERAPHY
 Treatment in which radiation source is at a distance from the body.
Linear accelerator and Cobalt machines are used in teletherapy
 Also called external beam therapy
 With external therapy the source of radiation is placed at a distance
5-10 times greater than the depth of tumor to be irradiated in order
to achieve uniform distribution of radiation to the tumor and thereby
avoid large dose variation attributable to inverse square law.
 The distance is called source
o to skin distance (SSD)
 Linear accelerator and Co60 machines are used commonly for
external beam radiation therapy

Three main types of radiation used in Radiation Therapy

1. Gamma rays
2. X-rays
3. Electron beams

• Electron beam therapy is the choice for skin and shallow target
in the body
• Gamma and X-ray will allow for the radiation dose to be given
to targets that are deeper in the body
• Gamma radiation typically use the radioactive material cobalt-
60. It is used because it emits high energy gamma rays as it
decay with a half life of 5.2 years
• Linear Accelerators (linacs) works by accelerating electrons
down a tube that will then either emit them as high energy
electrons or x-ray
• External Beam therapy can be broadly divided into kilovoltage therapy
and megavoltage therapy depending on the beam quality and their use

25
 KILOVOLTAGE THERAPY

1. Contact Therapy
- A contact therapy machines operates at potentials of 40 to 50
kV and facilitates irradiation of accessible lesions at very short
source (focal spot) to surface distance (SSD)

2. Superficial therapy
- The term superficial therapy applies to treatment with x-ray
produced at a energy ranging from 50 to 150 kV. Varying
thicknesses of filters (usually 1 to 6 mm of Al) are used to
produced beams of different qualities expressed in terms of half
value layer (HVL).
- The HVL is defined as that thickness of material which reduced
the intensity of narrow x-ray beam to half of its original intensity

3. Orthovoltage Therapy
- The term orthovoltage therapy or deep therapy is used to
described treatment with x-ray ranging from 150 to 500 kV
- Most orthovoltage equipment are operated at 200 to 300 kV

SUPERVOLTAGE THERAPY
 X-ray therapy in the range of 500 to 1000 kV has been
designated as high voltage therapy or super voltage therapy

MEGAVOLTAGE
 X-ray beam of energy of 1 MV or greater can be classified as
megavoltage beam
 Although the term strictly to the x-ray beams, the gamma ray
beam produced by radionuclides are also commonly included
in this category if their energy is 1 MeV or greater.
 Examples of clinical megavoltage machines are accelerator,
betatron, microtron and the telecobalt units

RADIATION SOURCES SIMULATORS

 A treatment simulator is an apparatus that uses a diagnostic x-ray
tube but duplicates a radiation treatment unit in terms of its
geometrical, mechanical and optical properties
 The main function of a simulator is to display the treatment fields so
that the target volume may be accurately encompassed without
delivering excessive irradiation to surrounding normal tissues

BRACHYTHERAPY
 A type of radiation therapy in which radioactive materials are placed
in direct contact with the tissue being treated
 Broadly it is of two types – interstitial or intracavitary

26
 BI - Interstitial
BC - Intra- Cavitary
BT - Not otherwise specified
US - Unsealed Source

 In intracavitary treatment, containers that hold radioactive sources

are put into the body cavities that are or in near the tumor (e.g.
intrauerine, vagina
 In interstitial treatment, radioactive sources may stay in the patient
permanently. Sometimes the radioactive sources are removed from
the patient after several days
 This technique is particularly useful in treating cancers of the cervix,
uterus, vagina and certain head and neck cancers.
 It can also be used to treat breast, brain, skin, esophageal, soft
tissue, lung, bladder and prostate cancer

*sometimes brachy therapy is done in conjunction with external

beam therapy. The external beam radiation destroys cancerous
cells in a large area surrounding the tumor. Brachytherapy delivers
a boost, or higher dose of radiation, to help destroy the main mass
of tumor cells

 If patient has two unrelated diseases both of which require

radiotherapy, each course of treatment should be recorded as a
primary source.
 Similarly if a patient has two primary lesions of the same disease
e.g. two rodent ulcers, the treatment of these comprises two
primary sources, unless the lesions are in such close proximity that
they are to be treated together
 If during a course of treatment, a patient starts a further course, the
second course should be separately identified

Note:
1. RADIUM-226 (T ½ = 1640 years) to produce gamma radiation
effects in limited volume of tissue is one of the oldest
established practices in radiotherapy
2. Radium-226 is an alpha emitter but within its decay scheme are
radium B (lead-214) and radium C (bismuth-214) emitting
gamma rays with energies in the range from 0.2-2.4 MeV; the
higher energy photon in the spectrum make radiation protection
difficult and the inert gas, radon-222 is a constant additional
hazard

CARE OF CLIENT WITH SEALED RADIATION SOURCE

1) Place a client in a private room with a private bath
2) Place a caution sign at the client’s door
3) Organize tasks to minimized exposure to radiation source
4) Limit time of 30 minutes per care provided per shift
5) Wear a dosimeter film badge to measure radiation exposure
6) Wear a lead shield to reduce the transmission of radiation
7) Do not allow pregnant to care for the client
8) Do not allow children younger than 16 years old to care or visit the
client

27
9) Limit visitors to 30 minutes per day; visitors should be 6 feet from
the source
10) Save bed linens and dressing until the source is removed; then
dispose of in the usual manner
11) Other equipment can be remove from the room at any time

DISLODGE RADIATION SOURCE

1) Do not touch a dislodge radiation source with bare hands
2) Used a long handled forceps to place the source in the lead
container kept in the client room and call the physician
3) If unable to locate the radiation source, prohibit visitors and notify
the physician

AIMS OF RADIOTHERAPY
- Radiotherapy is prescribed according to intention

1. Radical Radiotherapy
o This kind of treatment is intended to cure patient of their
disease
2. Palliative Radiotherapy
o Purpose of this treatment is to relieve the distressing
symptoms of an advance disease

ROLE OF RADIOTHERAPY TECHNOLOGIST

1. Responsible for carrying out prescribed treatment
2. Responsible in ensuring accurate and appropriate planning
and treatment technique
3. Responsible in monitoring side effects
4. Responsible in obtaining information that may be useful in
carrying out orders
5. It is also our responsibility to give moral support

HOW IS RADIOTHERAPY ADMINISTERED

1. Treatment is prescribed by Radiation Oncologist
2. Each course of treatment is usually consists of several doses or
fraction, each given on a particular date.
3. Radiotherapy Planning
4. One or more radiation beam or fields are directed towards at the
tumor site
5. The number of beams and the type of beam to be used are
selected, together with the level of radiation dose

FRACTIONATION AND TOLERANCE DOSE

 Fractionation of Treatment allows recovery of normal cells while
depleting the number of surviving tumor cell. The total dose
tolerated or tolerance dose depends on the dose per fraction, the
sensitivity of the tissue and the amount of recovery which can take
place between fractions

1. Fractionation and overall time

28
 o Dose that can be tolerated by normal tissue in the treatment
zone vary with the total time over which the dose is given.
o A dose can be delivered to a particular area over a weeks
which is larger than could be given in one week or one day

2. Volume Irradiated
o in general, the smaller the volume to be treated the higher the
total dose which may be tolerated, but the dose fractionation
schedule use also affects the normal tissue tolerance

3. Patient and Biological Factors

o The type of tissue treated, poor dietary and fluid intake or
concomitant treatment may affect the level of dose tolerated

OXYGEN EFFECT
 The size of the tumor influences the total dose and fractionation
which is required for tumor eradication.
 This effect is related to the number of cells which are well
oxygenated
 Good oxygenation increases the change of radiation damage to
cells.
 Cells are less susceptible to radiation damage if they are hypoxic,
as are many of the cells within a large cell mass where there is no
organized blood supply.
 Tumor cells therefore tend to be less well oxygenated than normal
tissue
 during the treatment course, outer oxygenated cell in the tumor
mass are damage, die and breakdown so that the next layer of cell
becomes oxygenated.
 in this way, the cell mass reduces with each fraction until all mass is
destroyed at the end of the course.
 Patient with low hemoglobin levels are usually transfused prior to
treatment to improve cell oxygenation in the tumor bearing zone

THERAPEUTIC RATIO
 The ratio of the maximally tolerated dose of a drug to the minimal
curative or effective dose; LD50 divided by ED50. i.e. in simple
language it is a balance between therapeutic effect and damage
caused as all cells exposed to radiation undergo some damage
 It is percentage of patients cured divided by the cost of the
treatment in terms of side effects
 The fewer the side effects without compromising the chance of
cure, the better the therapeutic ration
 Therapeutic Ratio should be major consideration in deciding
radiotherapy and can be improved by oxygenation, radiosensitizers
and hyper- fractionation

TECHNICAL FACTORS IN RADIOTHERAPY

 In any radiation treatment the clinician has to define the following
parameters

1. Tumor volume

29
 2. Target volume
3. Treatment volume
4. Radiation energy and quality
5. Number of fields
6. Arrangement of fields
7. Use of wedges, tissue compensator or bolus
8. Dose
9. Total number and frequency of fraction
10. Overall treatment time

DOSE FRACTIONATION AND OVERALL TREATMENT TIME

 It is essential to specify dose, energy, number of fractions and
overall treatment time together since each has an effect on the
biological response
 Stating a dose without specifying its energy, fractionation and
overall treatment time is meaningless

DOSE IN RADICAL AND PALLIATIVE RADIOTHERAPY

1. RADICAL
- In radical radiotherapy the choice of dose and fractionation
regime will depend on the radiosentivity of tumor, the size of
the treatment volume, the proximity of dose limiting critical
structures and the quality of radiation used
- Relative radiosentive tumors such as testicular seminoma can
be controlled by total doses of 30 Gy at megavoltage
fractionated over 4 weeks. Higher doses of the order of 50 – 55
Gy are neede to control most squamous carcinomas of the
head and neck
- The maximum tolerated dose of radical radiotherapy to different
volumes of tissue varies in different part of body
- Homogeneity of dose distribution across the target volume is
important to achieve maximum tumor kill . Areas of under
dosage may give rise to local recurrence and over dosage to
morbidity. For these reason the variation in dose across the
target volume should not vary by more than +/- 5% of the
intended dose

2. PALLIATIVE
- Homegeneity of dose distribution is much less important than in
radical radiotherapy
- Thus simple treatment techniques by single or parallel-opposed
fields will suffice for most purposes
- Since dose homogeinity is not essential, computerized planning
and the used of wedges to improve the dose distribution are not
needed
- Treatment volumes should be more generous than for radical
radiotherapy since the doses delivered should be well below
normal tissue tolerance
- Aimed at relieving local symptoms of advanced disease. The
following criteria should be applied to achieve good palliation:

30
1. Prompt relief of symptoms
2. Minimal upset from treatment
3. Simple treatment technique
4. Limited number of fractions

Assessment – Palliative Radiotherapy

 Patients with advanced disease may have a life expectancy
ranging from a few days to many months
 A judgment has to be made as to whether the patient is
likely to benefit within his or her expected life span
 In most cases benefit from palliative radiotherapy is seen
during or within a few days of treatment
 Where life expectancy is only a few days, every effort
should be made to control the patient’s symptoms at home
by medical means without recourse to radiotherapy
 Palliative radiotherapy should relieve symptoms with
minimal side effects. The amount of upset varies with site,
dose and fractionation

1. Site
- sites which tolerate palliative radiotherapy poorly are the
upper abdomen (sensitivity of the stomach and duodenum),
oral cavity (soreness and dysphagia) and perineum (painful
skin and vaginal reaction)
- Single fractions of 8Gy to the lower thoracic and upper
lumbar spine are likely to cause vomiting since some of the
duodenum will be incorporated in the field.
- Fractionated treatment is better tolerated
- Palliative radiotherapy is of value at a wide range of tumor
sites

Examples
1. Relief of hemoptysis, cough, dyspnea and mediastinal
obstruction in lung cancer
2. Control of bleeding in advanced bladder, rectal and cervical
cancer
3. Relief of pain from bone metastases
4. Relief of symptoms of raised intracranial pressure due to
brain metastases
5. Healing of ulcerating breast tumor

2. Dose and Fractionation

- Relatively low doses are adequate to relieve most
symptoms
- Single fractions of 8 Gy using orthovoltage, cobalt-60 or
megavoltage are suitable for ribs, upper thoracic spine, and
ling bones
- Fractionated doses, e.g. 20 Gy in four daily fraction or 30
Gy in 10 fractions are suggested for bony metastases in the
cervical, lower thoracic and upper lumbar spine and for
malignant spinal cord compression

Technique
- The treatment setup should be as simple as possible, with
single or parallel-opposed fields to limit the duration of each

31
 treatment

FRACTIONATION
 Refers to the division of the total dose into a number of separate
fractions, conventionally given on a daily basis, usually 5 days a
week (Monday to Friday).
 A single dose of 20 Gy may suffice to cure a small cell basal
carcinoma of the skin, but if given in five daily fractions (5 x 4 Gy) it
would be insufficient
 To achieve a comparable result would require 5 x 6 Gy (30 Gy)
 If we took 2 weeks (10 days sessions), the dose would be 10 x 4.5
Gy (45 Gy)
 As a general rule, the longer the overall treatment time, the higher
the total dose required

Number of Fractions Per Day

1. Conventional Fractionation
- Daily treatments from Monday to Friday with gap at weekends
remain standard for most radical treatments.
- However, there is wide variation in the overall treatment time

2. Hyperfractionation (Accelerated Fractionation)

- Instead of treating once a day, the number of daily fractions can
be increased, in practice rarely to more than three.
- This approach has been has been explored in tumors where
conventionally fractionated radiotherapy has often failed to cure
tumors (e.g. cerebral gliomas and advanced lung and head and
neck cancer)

2.1. Dose per fraction

- There is experimental evidence that as the dose per
fraction decreases, so too does the oxygen enhancement
ration
- Theoretically, with multiple small daily fractions the
importance of hypoxia as cause of radio-resistance in
tumors should be less marked compared with normal tissue

2.2. Morbidity
- in general, accelerated or hyper fractionated treatments are
associated with more severe acute reactions
- As stated above, acute reactions are determined by the
rate of accumulation of dose
- Unless small field sizes are used, the mucous membrane of
the head and neck will not tolerate fraction sizes of 2 Gy or
more given three times a day or more than 55 Gy in 2
weeks
- Late reactions are influenced by fraction size and generally
worse when the interval return fractions is less than 4.5
hours
- Late reactions are influenced by fraction size and generally
worse when the interval return fractions is less than 4.5
hours

32
3. Hypofractionation
- Refers to the practice of giving less than the conventional five
daily fraction per week
- This approach is illogical for treating sites sine long gaps
between fractions may allow tumor repopulation
- Hypofractionation is more logical in treating tumors with a
higher capacity for repair, e.g. melanomas and soft tissue
sarcomas and palliative radiotherapy
- In palliative radiotherapy, single fraction of 4-15 Gy for bone
metastases are in general as effective as multiple fractions to
total doses of 20-40 Gy
- A good and prompt pain relief can be achieved by a single
fraction of 8 Gy as by 30 Gy in 10 daily fractions
- Two fractions of 8.5 Gy given a week apart are as effective in
relieving symptoms of non-small cell lung cancer as 30 Gy in 10
daily fraction

THE 5 R’s OF FRACTIONATED RADIOTHERAPY

1. Recovery and
2. Repopulation - Lead to a decrease in response when
treatment is prolonged
3. Reassortment and
4. Reoxygenation - Are beneficial in a fractionated regime
5. Radiosensitivity - Baseline on which the other modification work

Radioprotectives Radiosensitizer
1. Zinc Oxide Oxygen
2. Pentoxiphylline Cisplatin
3. Etramustine 5-Fluorouracil
4. Amifostine Gemcitbine
5. Chlorhexidine Cytochlor
(for stomatitis)
6. Potassium Iodide Sr2508 (Estanidazole)
(for thyroid against radioiodine)
7. Melatonin Nitroimidazoles –
(protective for skin Metronidazole,
mitotic cell againts Misinidazole,
chromosomal Pimonidazole
damage)
8. Antioxidants (vit. C, E and A)

33
V. EXTERNAL BEAM RADIATION THERAPY
EQUIPMENT

KILOVOLTAGE UNIT

1. Grenz-Ray Therapy
- The term Grenz-Ray therapy is used to describe treatment with
beams of very soft x-ray produced at potential below 20 kV.
- Because of the low depth of penetration, such radiations are
no longer used in radiotherapy

2. Contact Therapy
- A contact therapy or endocavitary machine operates at
potential of 40 to 50 kV and facilitates irradiation of accessible
lesion at very short source to surface distance
- The machine operates typically at a tube current of 2 mA
- Applicators available with such a machine can provide an SSD
of 2.0 cm or less
- A filter of 0.5 to 1.0 mm thick aluminum is usually interposed in
the beam to absorb very soft component of the energy
spectrum
- Because of very short SSD and low voltage, the contact
therapy beam produces a very rapidly decreasing depth dose in
tissue.
- For that reason, if the beam is incident on a patient, the skin
surface is maximally irradiated but the underlying tissue spared
to an increasing degree of depth

3. Superficial Therapy
- The term superficial therapy applies to treatment with x-ray
produced at potentials ranging from 50 to 120 kV
- Varying thicknesses of filtration (usually 1 to 6 mm aluminum)
are added to harden the beam to a desired degree
- The HVL is define as the thickness of specified material
that when introduced into the path of the beam, reduce the
exposure rate by one half
- Typical HVLs used in superficial range are 1.0 to 8.0 mm Al
- The superficial treatments are usually given with the help of
applicator or cones attachable to the diaphragm of the machine
- The SSD typically ranges between 15 and 20 cm
- The machine is usually operated at a tube current of 5 to 8 Ma

4. Orthovoltage Therapy or Deep Therapy

- The term orthovoltage therapy or deep therapy is used to
describe x-ray produced at potentials ranging from 150 to 500
kV
- Most orthovoltage equipment is operated at 200 to 300 kV and
10 to 20 mA
- Various filter have been designed to achieve HVL between 1 to
4 mm Cu
- Although cones can be used to collimate the beam to desired

34
 size, a movable diaphragm, consisting of lead plates, permit a
continuously adjustable filed size
- The SSD is usually set at 50 cm to 70cm
- The maximum dose occurs close to the skin surface, with 90
percent of that value occurring at a depth of about 2 cm
- Thus, in a single field treatment, adequate cannot be delivered
to a tumor beyond this depth
- However, by increasing beam filtration or HVL and combining
two or more beams directed at the tumor from different direction
one can deliver a higher dose to deeper tumors
- There are severe limitation to the use of orthovoltage beam is
treating lesions deeper than two to three centimeters
- The greatest limitation is the skin dose, which become
prohibitively large when adequate doses are to be delivered to
deep-seated tumors

5. Supervoltage Therapy
- X-ray therapy in the range of 500-1000 kV has been designated
at a high voltage therapy or super voltage therapy

6. Van De Graaf Generator

- The Van De Graaf machine is an electrostatic accelerator
designed to accelerate charge particle
- In radiotherapy, the unit accelerates electrons to produce high
energy x-rays typically at 2 mV
- In this machine a charged voltage of 20-40 kV is applied across
a moving belt of insulating material
- A corona discharged takes place and electrons are sprayed
unto the belt
- This electron are carried to the top where they are removed by
a collector connected to a spherical dome
- As a negative charges collect on the sphere, a high potential is
develop between the sphere and the ground
- This potential is applied across the tube consist of filament, a
series of metal rings and a target
- The rings are connected to resistor to provide a uniform draft of
potential from a bottom to the top x-ray are produced when the
electrons strike the target

LINEAR ACCELARATOR
TREATMENT ENERGIES
 The range of energies employed in treatment delivery varies from 4
MV to a maximum of 25 MV; commonly, only beams of up to 10 MV
are used
 Typical x-ray energies for the treatment of head and neck or breast
are 4 to 6 MV
 For tumors sited deeper in the body e.g. pelvic tumors, energies of
8 to 10 MV are appropriate

CLINICAL ADVANTAGE
1. The dose absorbed is not dependent upon tissue type
2. Skin sparring and build up effect – the dose builds up in the first few
centimeters of tissues, and result in the skin receiving relatively lw
dose. Hence the skin is spared the maximum absorbed dose which

35
 delivered below the skin surface, contrasting with orthovoltage and
superficial beams

Relationship between Beam Energy and Depth of Maximum

Absorbed Dose
o Maximum absorbed dose is delivered at depth in centimeters of
one quarter of the beam energy in MV e.g. at 6 MV the
maximum absorbed dose is delivered at 1.5 cm tissue depth
o The build-effect must be considered during the planning
process. Skinsparring considered detrimental to the treatment
outcome can be reversed by adding a tissue-equivalent bolus
of an appropriate thickness

FUNDAMENTAL DESIGN FEATURES

1. Isocentric Mounting
- The linac is mounted to permit rotation of the gantry through
360degree, so that treatment fields may be directed at the
patient from any angle within the circle
- The position of the gantry is indicated by a protractor type scale
which should be visible during all routine treatment positions,
and well illuminated to enable it to be read in the dark
- The center of the circle described by the rotation of the gantry is
known as the isocentre

2. Isocentre Height
- The height of the isocentre floor affects the ease with which
patients can be accurately positioned, and is governed by the
designed and shape of the gantry arm and the treatment head
- The higher the isocentre the harder it to see the field light on
the patient’s skin

3. Rotation of the Collimators

- For the greatest flexibility in treatment field position of the
collimators must rotate through 360 degrees
- The position of the collimators should be indicated by an
analogue scale encircling the treatment head
- Computer controlled and verified linacs will also provide a
digital readout

4. Rotation of the Couch

- The couch rotates about the isocentre on a turntable, and the
scale indicating the position of the couch runs around the edge
of the turntable

5. Position of the Lasers

- Lasers mounted on the walls and the ceiling define the
isocentre at the lateral and anterior quadrants

SHAPING THE RADIATION BEAM

 To permit the treatment of areas of different sizes within the patient,
it is essential that the size and shape of the useful beam can be
altered

36
 The patient must be protected from any part of the radiation beam
not required for the treatment plan

1. Primary Collimation
- The primary collimator comprises a large block of lead or heavy
alloy with a conical aperture through which the useful beam
travels to the secondary collimation

2. Secondary Collimation
- is provided by two pairs of lead collimators of sufficient
thickness to absorb most of the primary beam
- They are conventionally moved in pairs symmetrically about the
central axis of the beam to permit variably sized treatment fields

WHY HAVE A SHARP EDGE?

 It is necessary to have a sharp edge so that only the tissue
intended to be treated is irradiated
 - Also areas may be treated which are next to critical organs such
as the eye
 The penumbra (dose gradient at the field edge) is wider on
teletheraphy units than on linacs, making linacs the machine of
choice

DEFINING THE FIELD LENGTH AND WIDTH

 The cross-sectional area of the radiation beam is referred to as the
treatment field
 The field size is defined by the field length e.g. along the patient,
and the field width e.g. across the patient, measured in centimeters
at the treatment f.s.d.

1. Linac Field Size Readouts

- Remote digital readouts of the collimators, with control switches
mounted on the handset
- This has necessitated the labeling of each collimator of the
radiation field
2. Setting Field Size

VISUALIZING THE RADIATION BEAM

 The area of radiation available after secondary collimation is made
to the eye by a light beam which is positioned in the treatment
head, so as to stimulate the radiation as closely as possible
 There are several method used to create a coincident light filed but
the most common employs a radio translucent foil mirror

1. Cross-wires
- A pair of fine cross-wires defines the centre of the radiation
beam in the light field
- This allow filed to be aligned on the patient by the field centre,
instead of by the edges

2. Rangefinder
- is a numerical scale, projected from the treatment head or
gantry arm, which indicates the distance in centimeters from the

37
 target to a surface

IMPORTANT FEATURES OF BEAM DEFINITION IN PRACTICE

1. The coincidence of the radiation beam with the light beam and the
rangefinder; accuracy must be normal treatment distance to within 2
mm
2. The light beam must be bright enough to be clear at extended f.s.d.
with the lead tray in situ
3. The cross-wires must be thin but clear so they can be seen on a
dark surface
4. The rangefinder must have wide spacing between the numbers and
sufficient graduations to permit accurate rangefinder setting across
the scale

QUALITY ASSURANCE
 A Linac is a complex piece of equipment. Safe and accurate
radiotherapy demands a well defined and consistent performance.
Monitoring this is the purpose of the quality assurance program

1. The specification
2. Acceptance and commissioning tests
3. Constancy Checks
4. The quality assurance programme
5. Monthly checks
6. Daily checks

Procedures for mechanical Checks

1. Accuracy of the rangefinder
2. Accuracy of the optical field size
3. Accuracy of the cross-wires
4. Accuracy of the fields light with the central axis
5. Accuracy of the lasers

HOW X-RAY AND ELECTRON ARE PRODUCED IN LINAC

 Linac use high frequency electromagnetic waves to accelerates
charged particles such as electrons to high energies through a linac
tube
 The electrons, injected at energy of about 50 keV interact with the
electromagnetic
 Fields of the microwaves and gain energy from the electrical field
by an acceleration process analogous to surf rider

COBALT- 60 MACHINES
 Radionuclide such as radium 226, cesium 137 and cobalt 60 have
used as sources of gamma ray for radiotherapy
 These gamma ray are emitted from the radionuclide as they
undergo radioactive disintegration
 Of all the radionuclide, cobalt 60 has proved to be the most suitable
for external beam radiotherapy

ADVANTAGE OF USING COBALT- 60

1. Are higher possible specific activity

38
2. Greater radiation output per curie
3. Higher photon energy
4. Radium is much more expensive and has greater absorption of its
radiation than either cobalt 60 and cesium

SOURCE
- The cobalt-60 source is produced by irradiating ordinary stable
cobalt-59 with neutron in a reactor
- Cobalt 60 source usually in the form of solid cylinder, disc or pellets
is contained inside a stainless steel capsule and sealed by welding
- The capsule is placed in another steel capsule which again sealed
by welding
- The double welded seal is necessary to prevent any leakage of any
radioactive material
- A typical teletherapy cobalt 60 is a cylinder of diameter of 1 to 2 cm
and is positioned in the cobalt unit with its circular end facing the
patient
- The fact that the radiation source is not a point source complicates
the beam geometry and gives rise to what is known as geometric
penumbra

Penumbra
- is the dose gradient produces outside the useful radiation beam

Implication of large Penumbra for Treatment Delivery

- The role of the cobalt 60 source machine is primarily the treatment
delivery for palliation to anatomical areas where less defined treatment
beam are acceptable

SHAPING RADIATION BEAM

- As gamma rays emanate in all directions the shielding if of equal
thickness all around the source
- The housing must be of sufficient thickness to reduce the emission
to the required limit; to ensure the safety of the radiation therapist
and patient

COLLIMATORS
- Consist of pairs of heavy metal blocks
- Each pair can move independently to obtain a square or a rectangle
shaped field
1. Primary Collimators
- is a conical hole in the source shielding through which the
useful beam is emitted

2. Secondary Collimators
- The collimation and field definition are similar to linac

3. Penumbra Trimmers
- are heavy metal blocks which can be mounted on to the
treatment head so that the inner faces of the blocks are parallel
with the divergent gamma ray beam

39
Practical Implication of Additional Radiation Protection
1. The main hazards is the possibility that the source may stick in the
treatment position
2. A further potential source of radioactive exposure results from the
possibility of a source leaking from its content.

COBALT- 60 EXTERNAL BEAM MACHINE VERSUS LINAC

1. Cobalt 60 machine have no asymmetric or independent jaws which
are important for many radical treatment technique
2. The relatively low machine output and slower machine movement
give rise to a much lower patient throughout
3. Cobalt 60 machine have a large penumbra
4. The cost of new source is high and the cost of disposing of spent
sources has recently risen
 Cobalt-60 - has a half life of 5.26 years and a beam energy
equal 2 MV

BRACHYTHERAPY
 is the application of small sealed sources directly to the body either
from within or near the surface
 the sources are position central to or evenly spaced throughout the
volume of tissue which require treatment

TYPES OF BRACHYTHERAPY
1. Intracavitary
- Small source pellet are introduced into a catheter which has
been previously inserted into a body cavity or lumen
- e.g. ureters, cervix, prostate, esophagus

2. Implants or Interstitial
- Radioactive source is directly applied to tissue at or near the
surface of the body using surgical technique to insert guide
tubes or catheter

3. Intraoperative
- delivered during operative technique
- Treatment delivery to patient who had catheter positioned
which is in the operating room and then receives treatment
receive via these applicator

AFTERLOADING PRINCIPLES AND EQUIPMENT

1. After loading allows the accurate placement of source carrier within
the body
2. Positional Verification (orthogonal film taken)
3. before radioactive sources are introduced
4. Greater precision in source positioning without radiation to staff

Remote after loading system

- controls radioactive sources which are contained within them
and connected applicator system via computer keyboards
(positioned outside the treatment room)

40
BASIC STEPS IN TREATMENT PROCEDURES
1. Catheter or applicator are introduced into a conscious anesthetized
or sedated patient
2. Various type of applicator are connected both to the patient and to
the machine
3. The applicator positioned is radio graphically checked to verify
alignment with each other and the anatomy
4. Dose distribution for a particular patient or tumor geometry is
determined from film by measurement and calculation
5. The required source arrangement is programmed independently for
each channel

EQUIPMENT
Source Type
- Sources used within the after loading unit may be one of the
various isotopes, formed into a small pellets, ribbon or wires
- Some of the units use a combination of 48 spacer and sources in
continuous line known as source train
- Alternatively, single stepping, a source pellet may be used. The
pellet move to a preset ‘step’ position within the applicator, remain
there (dwells) for a set of time, then moves forward to the safe in a
stepping fashion, staying for preset times at any desired point

Cobalt- 60
- the 20 equal activity sources are 1.5mm x 1.5mm steel-
encapsulated cylinder which form of outer diameter of 2.5mm
- Half life Cobalt - 5.26 years

Cesium 137 LDR/HDR - Half Life Cesium - 30 years

Iridium 192 HDR - Half life 74.3 days
Radium - 1600 years

Micro Selection- HDR 192r

- Is a high dose rate interstitial and intraluminal system.
- It is consist of a treatment unit in which a single source stored
within the shielded safe.
- The source can be remotely after loaded into a small diameter
catheter (less than 2mm) for high dose rate intraluminal
treatments or interstitial implants
- Dose distribution are obtained by programming dwell positions
and times for the single source for each applicator

Source
- Iridium- 192 source is 1.1mm in diameter with an active length
of 3.5mm
- The rigid needles or flexible plastic applicators have an outer
diameter of 1.9mm
- An 18 channel indexer automatically guides the source
successively through 1-18 applicators according to
programmed requirements

41
 Quality Assurance
- An integrated check cable run out to the distal program dwell
point to check the system and applicators for constriction,
before the source leaves the safe
- Battery back up and software features provide a means to
retain source programs and treatment details in the event of
power failures, when the source is automatically returned to
safe

Treatment Interruption
- Treatment can be interrupted if necessary, when sources are
returned to safe positions and treatment timers stopped;
remaining treatment times are indicated and monitored
- Sources will not be transferred to the applicator if the
connections are not correctly made

THE FOLLOWING SHOULD BE CHECKED REGULARLY BY A

PHYSICIST
1) Coupling and connection interlocks
2) Door and other interlocks
3) Sources and transport mechanism
4) Machine function
5) Interrupt and termination functions
6) Timers
7) Treatment programming function and procedures
8) All applicators
9) Source positioning accuracy and reproducibility

*Checks which are the responsibility of the radiographer using the

unit
-it is advisable to check that the expected source configuration
and approximate times are shown in the display/ printout when
giving treatment, to detect possible error
Procedure such as interrupts, door interlocks and the exposure
monitoring system should be checked daily before clinical use,
and all the results are recorded

Isoeffects Surfaces
- An envelope of tissue surrounding the sources has layers
receiving equal dose, and therefore equal effects. These may
be referred to as isoeffect surfaces, which differ in position for
early and late effects
- Acute and late isoeffects and the overall effects of the different
dose rates are dose time dependent
- The radiation related morbidity increases with dose per fraction
and with reductions in fraction number

HIGH DOSE VERSUS LOW DOSE RATE

Advantage of HDR
1. Short treatment time
2. No major anatomy changes during the short treatment time
3. Rigid fixed geometry multi applicator system may be used
4. Applicator can be inserted in the treatment room without local

42
 anesthetic
5. Good patient acceptance because treatment can be given out
patient
6. No requirement for projected patient room
7. No overnight nursing staff required

Advantage of LDR
1. Equivalence with radium dose rate, so that clinical can be well
predicted
2. Less damage to normal tissue
3. The dose to adjacent organs may be spread out due to organ
movement during the treatment time

SIMULATORS
 A treatment simulators is a machine that is capable of duplicating
the geometry and mechanical movement of radiation therapy
machines but uses a diagnostic x-ray tube
 A simulator is primarily used to localized target volume and normal
tissue with respect to skin marks and visualized the plan treatment
fields with respect to tumor an abnormal tissue
 Following confirmation and correct field location and direction, the
fields are marked on the skin surface and shielding blocks are
produce to optimize normal tissue sparring
 The use of simulators has improved the precision of radiation
therapy because it provides a diagnostic x-ray quality radiograph of
the treatment field taken with precise geometric relationship to the
treatment beam
 The range of distance and the field size of most therapy machine
can be reproduced by moving the x-ray tube along an arm that is
capable of 360 degrees rotation
 The distance from the target to the isocenter can therefore easily
changed
 Many simulators have fluoroscopic capabilities providing real time
visualization of internal organs, of contrast placed in the body
cavities, and of lead markers put on the skin surface
 Field defining wires, built in the path of the beam, can be moved to
stimulate the planned treatment field
 A small circle or cross hair indicates the central axis of the beam
 Some simulator can provide a grid that project a centimeter scale at
the isocenter. This facilitates easy measurement of real size on the
magnified radiograph

SUBJECT: RADIATION PROTECTION AND SAFETY STANDARDS

FOR THE PRACTICE OF RADIATION THERAPY UTILIZING
MEDICAL LINEAR ACCELARTOR MACHONES IN THE
PHILIPPINES

 The radiation protection and safety standards for the practice of

radiotherapy utilizing medical linear accelerator machines are
issued pursuant to Presidential Decree 480, otherwise known as
“Creation of Radiation Health Office” in 1974 as amended by

43
 Presidential Decree 1372 in 1978 and Executive Order 119,
otherwise known as the “Reorganization Act of the Ministry of
Health” in 1987, as revised by Executive Order No. 366, otherwise
known as “Directing a Strategic Review of the Operations and
Organization of the Executive Branch and Providing Options and
Incentives for Government Employees Who May Be Affected by
the Rationalization of the Functions and Agencies of he Executive
Branch” in 2004 and Administrative Order No. 149 s. 2004,
otherwise known as “Basic Standards on Radiation Protection and
Safety Governing the Authorization for the Induction and Conduct of
Practices Involving X-ray Sources in the Philippine”.

 On August 18, 2009, Republic Act No. 9711 known as the Food and
Drug Administration (FDA) Act of 2009 was enacted into Law
creating the Center for Device Regulation Radiation Health and
Research (CHDRHR) of the FDA, strengthening the regulation of
the use of radiation devices and operation of radiotherapy facilities.

 These standards are promulgated foe the purpose of assuring

quality radiation treatment and ensuring the protection and safety of
patients and workers occupationally exposed to radiation and the
member of the general public, from the hazards associated with the
use of medical linear accelerator machines. These standards are
based on the International Basic Standards for Protection against
Ionizing Radiation and for the Safety of radiation Sources (IBSS)
published as International Atomic Energy Agency (IAEA)
International Basic Safety Series 115 Report

Definition of Terms
Acceptance Testing
 test procedures done to verify that the equipment conforms to
technical specifications given by the manufacturer and to verify
compliance with safety requirements from IEC or other international
and national standards (IEAE Publication 1296)

Assistance Radiation Protection Officer

 An individual who has proper training ad qualification on radiation
protection and safety. Assist the RPO and assumes his/her
responsibilities in behalf of his/her absence. (Radiation Safety
Officer)

Center for Device Regulation, Radiation Health and Research

(CDRRHR)
 Is the national regulatory agency with responsibility for radiation
protection from electrical/ electronic devices capable of emitting
radiation. Its former name is Bureau of Health Devices and
Technology

Conformance Testing
 Test procedures done on equipment to verify it conformance to the
standards set by CDRRHR.

Conventional Radiotherapy Services

44
 Is a basic radiotherapy service using the standard/ routine
procedures and technique.

Controlled Area
 An area is which specific protection measures and safety provisions
are needed to control normal exposure and to prevent potential
exposure. It includes all irradiation rooms for external beam therapy
and the control panel area (IAEA Publication 1296)

Full Time
 Refers to an employee’s normal or standard amount of working
time of eight (8) hours per day.

Individual Monitoring Device

 A radiation sensitive device (e.g. film badge, TLD badge, pocket
dosimeter, electronic pocket dosimeter) used to estimate the dose
received by a worker on the course of his/her duty.

Interlock
 A device or system that automatically shuts off or prevents the
emission of radiation from equipment when activated.

International Atomic Energy Agency (IEAE)

 An independent intergovernmental organization within the United
Nation’s System that serves as the world’s central inter-government
forum for scientific and technical co-operation in the nuclear field,
and as the international inspectorate for the application of nuclear
safeguards and verification measures covering civilian nuclear
programs.

International Electro technical Commission (IEC)

 An independent organization that prepares and publishes
International Standards for all electrical, electronic and related
technologies, collectively known as “electro technology”. The
organization also manages conformity assessment system that
certify equipment, systems or components conform to its
International Standards

International Commission on Radiological Protection (ICRP)

 an independent non-governmental organization of scientist that
serves as an advisory body providing recommendations and
guidance on radiation protection

Maintenance/ service personnel

 A person registered with the CDRRHR and certified by the
equipment manufacturer to have completed a training program in
the maintenance (preventive and corrective) and servicing a
particular brand and model of therapeutic x-ray equipment or its
components spare parts and the scope of the service/maintenance
work. He shall have completed a training course in radiation
protection in the servicing or radiotherapy equipment conducted by
an institute or organization/ accredited by CDRRHR

Manual
 DOH Department Circular No. 323 s. 2004, Manual on Basic

45
 Radiation Protection and safety of X-ray sources in the Philippines

Medical Linear Accelerator

 A type of therapeutic radiation equipment which can be operated
either in the x-ray electron beam mode. It uses high frequency
electromagnetic waves to accelerate electrons to high energies
through a linear tube

Philippine Nuclear Research Institute (PNRI)

 A scientific institution under the Department of Science and
Technology (DOST) dedicated to the promotion, research and
regulation of the peaceful uses of atomic energy.

Quality Assurance Program

 A management tool which, through the development of policies and
the establishment of review procedures aim to ensure that every
examination or treatment necessary, appropriate and performed
according to previously accepted clinical protocols by adequately
trained personnel using properly selected and functioning
equipment to the satisfaction of the patient and referring physicians
safely and minimum cost.

Quality Audit
 The operation carried out to measure or evaluates the performance
of radiotherapy facility which can be undertaken internally by the
institute itself or externally through an internal audit group.

Quality Control
 Specific tests required to ensure effective and safe equipment
performance and/or measures that are taken to restore, maintain/or
improve the quality of treatment.

Radiation accident
 Any unintended event, including operating errors, equipment
failures or other mishaps, the consequences or potential
consequences of which are not negligible from the point of view of
protection safety.

Radiation incident
 Any event which has occurred and conformed to have affected a
specifically defined area in the radiation therapy department with
actual or projected radiation levels which are expected to be in
significant quantities resulting in overexposure of a worker
exceeding the annual dose limit based on ICRP 60.

Radiation Oncologist
 A medical specialist in the practice of radiotherapy and is charged
with specific responsibilities as indicated in this AO and in Appendix
I of the IEAE Publication No. 1296

Radiation Oncology/ radiation Therapy (Radiotherapy)

 A multidisciplinary specialty in medical science that deals with the
medical management of malignancies and allied diseases utilizing
ionizing radiation and complex equipment for the delivery of the
treatment

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Radiation Oncology Medical Physicist (ROMP)
 A qualified expert in radiotherapy physics who is charged with
specific responsibilities indicated in this AO and I Appendix I of
IAEA Publication No. 1296

Radiation Protection Officer (RPO)

 An individual who has proper training and qualification on radiation
protection and safety. He/she could be a medical physicist,
radiation oncologist or Radiation Therapy Technologist designated
by the registrant or licensee who is technically competent in
radiation protection matters in the practice of radiotherapy/radiation
oncology and is charged with the responsibility to oversee the
application of the requirements of the International Basic Safety
Standards for Protection against Ionizing Radiation and for the
Safety of Radiation Sources as specified in the Manual.

Radiation Protection Committee (RPC) or Medical radiation

Committee (MRC)
 Is a committee that oversees the whole operation of the
radiotherapy/radiation oncology facility and reviews the facility’s
quality assurance and radiation safety programs. It shall be
composed of but not limited to the following personnel: chief
radiation oncologist, radiation oncology medical physicists,
radiotherapy technologist and representatives from the nursing
service administrative service.

Radiation Therapy/ Radiotherapy Technologist (RTT)

 A radiologic technologist duly licensed by the Professional
Regulation Commission.

Radiological Emergency
 A radiological incident that poses an actual, potential or perceived
hazard to public health or safety, loss of life, disability or damage to
property.

Refurbished equipment
 Previously owned therapeutic x-ray equipment that underwent
restoration of its performance and safety specification by its
manufacturer through repair and/ or replacement of parts and
issued a test certificate prior to release for clinical use

Specialized radiotherapy services

 Refers to complex radiotherapy procedures and techniques
“dealing with specific problems” which usually require equipment
modifications, special quality assurance procedures and heavy
involvement and support from medical physicist. These include
intensity modulated radiotherapy (IMRT), conformal radiotherapy
(CRT), stereotactic radiosurgery (SRS), stereotactic radiotherapy
(SRT), stereotactic body radiotherapy (SBRT), intra-operative
radiotherapy (IORT), total body irradiation (TBI), total skin electron
irradiation (TSEI), endocavitary rectal irradiation, image-guided
radiotherapy (IGRT), respiratory gated radiotherapy, Tomotherapy,
Cyber Knife and other techniques as may classified as specialized
by CDRRHR.

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Standards
 Radiation Protection and Safety Standards for Radiotherapy
Utilizing Medical Linear Accelerator machines in the Philippines

Supervised Areas
 Any areas not already designated as a controlled area but where
occupational exposure conditions need be kept under review even
although specific protection measures an safety provision are nor
normally needed (IAEA Publication 1296)

Supervising radiologic Technologist

 Chief Radiotherapy Technologist

Therapeutic X-ray Equipment

 Medical linear accelerator equipment used for the treatment of
patient with malignancies

Therapeutic X-ray Facility

 A standing or hospital based radiotherapy center utilizing medical
linear accelerator x-ray machines.

World Health Organization (WHO)

 A specialized agency of the United Nations with primary
responsibility for health matters an public health which was
established on 7 April 1948, whose objective is the attainments by
all peoples of the highest possible level of health that will lead the,
to a socially and economically productive life.

Focus……………………. Set Priorities

If you chase two rabbit, both will escape

Prepared By:

Jonalyn Duque Rivera, RRT, RN, USRN, MAN

College of Radiologic Technology

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